Screening for Lung Cancer

Transcription

1 Screening for Lung Cancer 15 ΜΑΡΤΙΟΥ 2014 Ioannis Gkiozos Pulmonologist Oncology Unit G P General & Chest Diseases Hospital Sotiria Despite advances in therapy, 5-year survival rates of Lung Cancer Remains Low 1

2 We have to use all the help that we can get Definition of Screening Test Screening can be defined as the systematic testing of individuals who are asymptomatic with respect to some target disease. The purpose of screening is to prevent, interrupt, or delay the development of advanced disease in the subset with a pre-clinical form of the target disease through early detection and treatment. Hillman et al. JACR 2004;1(11):

3 Principles of Screening Screening vs Diagnosis Non-patients Asymptomatic Test non-diagnostic Low prevalence Patients Symptomatic Test diagnostic High prevalence Principles of Screening Timeline of Disease PRECLINICAL CLINICAL screening Onset of Disease Detectable by Test Signs or Symptoms Death from Disease or Other causes 3

4 Principles of Screening Screening Effective screening Onset of Disease Detectable by Test Critical Point Signs or Symptoms Death from Disease or Other causes Principles of Screening Screening Ineffective screening Onset of Disease Critical Point Detectable by Test Signs or Symptoms Death from Disease or Other causes 4

5 Principles of Screening Screening Unnecessary screening Onset of Disease Detectable by Test Signs or Symptoms Critical Point Death from Disease or Other causes Principles of Screening Led-time Bias The diagnosis of disease is made earlier in the screened group, resulting in an apparent increase in survival time (lead-time bias) although the time of death is the same in both groups. The natural history of the disease is not changed. Patz EF et al. New Eng J Med 2000;343:1627 5

6 Principles of Screening Length-time Bias The probability of detecting lung cancer is related to the grouth rate of the tumor. Length-time bias occurs when screening detects less aggressive tumors, in which the tumor detectable period is larger.thus, patients whose tumors are identified by screening may appear to have better outcomes, but their tumors may differ biologically from the general cohort of patients with that cancer. Patz EF et al. New Eng J Med 2000;343:1627 Principles of Screening Overdiagnosis Bias Overdiagnosis refers to histologicaly confirmed lung cancers identified through screening that would not affect the individuals lifetime if left untreated. Black WC. Cancer

7 SCREENING FOR LUNG CANCER Every breath you take I ll be watching you HISTORY OF LUNG CANCER SCREENING Randomized trials of screening with the use of Chest X-Ray with or without cytologic analysis of sputum specimens have shown no reduction in lung cancer mortality. Molecular markers in blood, sputum, bronchial washingsbrushings are not currently suitable for clinical application. Several observational studies have shown that low-dose helical CT of the lung detects more nodules and lung cancers, including early-stage cancers, than does chest radiography. NLS Prospective Randomized Controlled Trial (2011): Annual Screening with the use of low-dose CT, 20% REDUCES mortality from lung cancer, in high-risk groups. 7

8 HISTORY OF LUNG CANCER SCREENING 8

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10 Inclusion Criteria: NLST Enrollment Criteria Aged yrs 30 or more pack-yrs* of cigarette smoking history Former smokers: quit smoking within the previous 15 yrs Exclusion Criteria: Metallic implants or devices in the chest or back, such as pacemakers or Harrington fixation rods Treatment for or evidence of any cancer other than nonmelanoma skin cancer or carcinoma in situ (with the exception of transitional cell carcinoma in situ or bladder carcinoma in situ) in the 5 yrs prior to eligibility assessment History of lung cancer History of removal of any portion of the lung, excluding needle biopsy Requirement for home oxygen supplementation Participation in another cancer screening trial Participation in a cancer prevention study, other than a smoking cessation study Unexplained weight loss of more than 15 lbs in the 12 mos prior to eligibility assessment Recent hemoptysis Pneumonia or acute respiratory infection treated with antibiotics in the 12 wks prior to eligibility assessment Chest computed tomography examination in the 18 mos prior to eligibility assessment 1060 (645/ person-years 941 (572/ person-years) 425 (309/ person-years) 346 (247/ person-years) 10

11 QUESTIONS ON NLST Cost-effectivnes? The NLST investigators are performing cost-efficacy analysis per life year saved. High risk patients? Can we extrapolate the NLST results to other individuals? Modeling analysis is needed in order to define high risk groups. Interval time and screening period time? Clinical trials will address this obvious issue. Never smokers can develop lung cancer, do they need screening? New studies are needed, NLST investigators collected serial blood samples from participants & multiple analysis of potential biocorrelatives is under investigation. 11

12 WHO SHOULD WE SCREEN IN CLINICAL PRACTISE? LUNG CANCER SCREENING GUIDELINES American College of Chest Physicians National Comprehensive Cancer Network. American Society of Clinical Oncology. American Cancer Society. International Association for the Study of Lung Cancer American Association for Thoracic Surgery American Lung Association. American Thoracic Society British Thoracic Society 12

13 The landmark NLST trial has demonstrated that LDCT is the first clinical tool that demonstrates a significant reduction in lung cancer mortality, in the USA. These initial results support the premise on which the UKLS trial has been developed. However, we await the outcome of the UK screening trial to guide National Health Service decision makers on the future of lung cancer screening within the U.K. 13

14 J Thorac Cardiovasc Surg 2012;144:33-8 J Thorac Cardiovasc Surg 2012;144:33-8 J Thorac Cardiovasc Surg 2012;144:

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17 Identification of high-risk individuals for lung cancer CT screening programs. Develop radiological guidelines for use in developing national screening programs. Develop guidelines for the clinical work-up of indeterminate nodules resulting from CT screening programmers. Guidelines for pathology reporting of nodules from lung cancer CT screening programs. Recommendations for surgical and therapeutic interventions of suspicious nodules identified through lung cancer CT screening programs. Integration of smoking cessation practices into future national lung cancer CT screening programs. 17

18 PERSONAL VIEW Task Force for Screening Lung Cancer of Hellenic Medical Societies, to develop National Guidelines according to IASLC Recommendations & NLST final results. A fool with a screening tool is still a fool MAURICIO CATTELAN, UNTITLED, 2004 Courtesy: The Dakis Joannou Collection 18